Inspection on 09/02/07 for 22 St Peter`s Road

This inspection was carried out on 9th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

22 St Peter`s Road 28/01/09

22 St Peter`s Road 02/11/05

22 St Peter`s Road 04/05/05

22 St Peter`s Road 06/10/04

22 St Peter`s Road 22/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 22 St Peter`s Road St Leonards on Sea East Sussex TN37 6JG Lead Inspector Caroline Johnson Key Unannounced Inspection 9th February 2007 09:30 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 22 St Peter`s Road Address St Leonards on Sea East Sussex TN37 6JG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01424 447851 01424 447851 rjralph22@tiscali.co.uk A S D Unique Services Limited Position Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is 4. Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. To allow a specific service user who has a dual diagnosis to be admitted to the home. 2nd November 2005 Date of last inspection Brief Description of the Service: 22 St Peters Road is situated in a residential area in St Leonards on Sea. The home is registered to accommodate four adults with autistic spectrum disorders. The property is a three storey building with bedrooms situated on the first and second floors. The home is close to shops and amenities and there is easy access to Hastings and St Leonards. 22 St Peters Road is one of four homes owned by the proprietors Mr and Mrs Kennard. The current scale of charges for the service range from £1,150 to £1,780 each week. Additional charges are made for hairdressing, toiletries and magazines. The service provides a contribution to hairdressing costs. Inspection reports are made available at the home and reference to the availability of reports is also included in the home’s statement of purpose. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process a site visit was carried out on 9/2/07. The inspection lasted from 10.00am until 6.40pm. During the visit there was an opportunity to speak with two of the three residents and to meet with one of the proprietors, the acting manager and one other member of staff. In addition a wide range of records were examined including, care plans, staff recruitment records, staff training records, health and safety documentation and records held in relation to complaints and adult protection. A full tour of the building was not undertaken but all communal areas were seen along with one of the bedrooms. There was also an opportunity to join two of the residents for lunch. In addition to the site visit attempts were made to contact two relatives/friends of the residents but contact was only made with one. Feedback received was very positive with comments such as ‘the care is very good’ and the resident ‘has moved on in leaps and bounds since moving into the home’. In addition comment cards were sent to the home prior to the inspection for distribution to the residents. Two comment cards were returned. Both residents choose to tick responses rather than make comments with the exception of the question on ‘Do you know who to speak to if you are not happy’. For this question both residents detailed whom they would speak to if they were not happy. All other ticked responses were positive. Since the last inspection the registered manager has transferred to manage another care home within the company. The senior carer at that time was promoted to acting manager. She has yet to apply for registration as manager. What the service does well: What has improved since the last inspection? 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 6 The owners have recently taken over the recruitment of new staff for the home. The manager will continue to be involved in the interviewing and selection of all new workers. A new reference request letter has been designed to ensure that more detailed information is requested. The owners have also confirmed that they are taking over the carrying out of monthly, unannounced visits to the home. This task had been delegated previously to managers within the company but over the summer months it had not been done on a regular basis. Quality assurance systems have improved and as part of this process satisfaction questionnaires were sent to the relatives of the residents to seek their views on the quality of care provided in the home. As a result of the questionnaires some new practices have been introduced in the home such as residents being more involved in meal preparation. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. When the minor amendments have been made to the statement of purpose the document will provide prospective residents with detailed information about the home. EVIDENCE: The statement of purpose has not been amended since the last inspection and will need to be updated to reflect the changes to the management of the home. There have been no new admissions to the home since the last inspection. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Care plans provide detailed information about the needs and abilities of residents. The planned reassessment of needs and abilities and clearer goals should assist staff to record more clearly the work they do to assist residents to achieve their goals. The home is good at ensuring that staff have clear guidelines on how to management any behavioural problems. EVIDENCE: Two care plans were looked at on this occasion but a detailed examination was not carried out as the acting manager advised that a full reassessment of each resident’s abilities and needs is to be carried out and from this individual plans will be drawn up. Records showed that staff had been reviewing the plans at regular intervals as there were signatures in place but there were very few additions being made to the care plans. As a result some of the care plans had been in place a long time. Each of the residents has a number of identified goals and from the record keeping it is not always easy to see what progress is being made. A discussion was also had with one of the owners about care 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 10 planning and it was agreed that time would be given to review and update the care plans. There are detailed guidelines in place for staff to follow in relation to the management of behaviour problems and risk assessments detail the action required by staff to minimise the risk of accidents/incident occurring. One of the residents is now using a calendar, which is proving very useful to aid communication. Staff reported that use of written information is helping the resident to develop new skills in communication. House meetings are held weekly. House issues are discussed and outcomes or reasons for decisions being reached are documented. Each week the residents choose the menus for the weekend and the activities that they wish to participate in. The acting manager advised that she would like to change the format for recording the minutes so that more detailed information can be recorded. One of the residents advised that the acting manager is going to bring in a range of brochures so that they can choose their annual holiday. She also stated that they recently chose the blinds for the lounge. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is good at ensuring that day activities are varied and stimulating and that they are kept under regular review to ensure that the residents continue to enjoy what they do. EVIDENCE: Following a knee replacement operation, one of the residents has become much more independent and the home are supporting her to be more active. In the spring she will be starting a new work placement one day a week. This placement involves horticulture and subject that she advised she loves and she stated that she is looking forward to it. She also wants to get into a college course. She is now much more mobile and enjoys walking and activities such as swimming and gym. She continues to play and receive tuition in the keyboard twice a week and has also taken up knitting, a hobby that she used to enjoy in the past. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 12 Another resident advised that her timetable includes, gym, bowling and swimming. She also stated that she attends college one day a week to do music and drama. She likes to go to the pub at least once a week and they generally meet up with the men, from one of the other homes within the company, for this activity. This resident stated that sometimes activities have to be changed at short notice if one of the residents decides not to go. Generally this does not bother her but occasionally it does if she is really looking forward to an activity. The acting manager advised that there has been a staff vacancy and they are currently recruiting to this position so hopefully when this happens they will be able to respond more flexibly to accommodate the different wishes of the residents. Staff advised that they have recently introduced TEACCH methods for aiding communication with one of the residents. For this resident symbols will be used to clarify her various routines each day. Progress will be reviewed on a regular basis. There is a four-week menu in place, which is set for Monday to Thursday. At the weekly house meetings residents choose the meals for the weekends. Records seen showed that there is variety and that meals are well balanced. Residents often choose alternatives to the set menu and as the home is small they are able to be flexible and to adapt easily to the changes made. Alternatives to the menu are not always recorded but the manager advised that a staff member has been designated the task of working on the menus to ensure better recording and advice regarding meal preparations. Lunch was had with two of the residents, during the inspection. One of the residents stated that recently, they had become more involved in meal preparation and that they are also more involved in cleaning up after meals. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The arrangements in place for the management of medication are very good. Attention needs to be given to recording medication administered to residents. The new competency based assessment should improve the system even further. It is acknowledged that it has been a difficult year for the staff team and the residents, as one of the residents died, and the home is to be commended for their professionalism and the support provided to the residents at that time. EVIDENCE: Medication is stored appropriately and a daily record is kept of the temperature of the medication cupboard. It is possible to carry out an audit of all medication received into the home. There is a signing in/out book in place and a record is kept of all medication returned to the home’s pharmacy. Records showed that there were some gaps in the recording of medication administered to residents. Staff receive regular training on the medication in use in the home. The acting manager advised that one carer is due to receive training and one member of staff is due to attend a refresher course. It was also reported that the home is going to introduce a competency assessment for all 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 14 staff. All new staff will need to pass the assessment prior to administering medication in the home. All regular staff will periodically be tested to ensure that competency is being maintained. Since the last inspection one of the residents has died. Residents spoke very openly about the death of the resident and about the very good support and care provided to them by the staff team. There were also thank you cards from the family of the deceased resident detailing their gratitude for the support shown to them. One of the residents had a knee replacement last year and it was noted that along with increased mobility this resident has now developed more independence and confidence. Where it is assessed that specialist advice or support would be beneficial then arrangements are made for this to happen. Recent referrals have been made in relation to sexuality advice and bereavement counselling. One resident chose to have spiritual guidance from a local minister in relation to bereavement issues. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home responds well to any complaints made to them. They are thorough in their recording of adult protection issues ensuring that residents are protected as far as it is possible to from abuse of any kind. EVIDENCE: There is a detailed complaint procedure in place ensuring that anyone wishing to make a complaint can do so. Records showed that since the last inspection there had been three complaints. In relation to one of the complaints attempts had been made to contact the complainant to discuss the complaint but this had not been successful. The acting manager agreed that perhaps a letter could have been written but the complaint had occurred prior to her taking on the manager’s role. The home had also made a complaint to an external organisation on behalf of one of the residents and this had reached a satisfactory outcome for the resident. The Commission has not received any complaints about the service. The home keeps a record of all adult protection alerts made to Social Services. Records showed that there had been fifteen alerts made since the last inspection. More recent alerts had been of a minor nature. There are detailed procedures in place and all of the staff team have had training on the subject. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is decorated to a good standard and the continual programme for redecoration ensures that this standard is maintained. Fire doors propped open present a risk in relation to fire safety and if it is assessed that doors should be kept open then self-closing devices should be fitted. EVIDENCE: One of the residents showed the inspector her bedroom. It had recently been painted and she stated that she choose the colour for her room. The room was homely and had been personalised. There is a maintenance record in place showing any work identified that needs to be done and a record is made when the work has been attended to. The door to the dining room was propped open at intervals during the inspection. The dining room is due to be decorated in the coming year. The lounge, kitchen and laundry room were also seen and all areas were clean and well decorated. Since the last inspection a new carpet has been fitted in the 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 17 lounge and a new suite of furniture has been purchased. The kitchen has been retiled and repainted. A cleaner is now employed to carry out cleaning duties two mornings each week. In relation to fire safety, records showed that the home carries out regular tests of the equipment in place and that all equipment is serviced. The home’s fire risk assessment was carried out in 2003. The last drill was held in October 2006 and an evaluation was carried out of this drill. One resident did not respond and the home’s records stated that another drill should be carried out but this has yet to be done. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures are thorough. There are very good training opportunities for staff ensuring that there is a well-qualified team in place. Staff receive regular supervision and support. The home should continue towards meeting their target to have 50 qualified to National Vocational qualification (NVQ) level two or above. EVIDENCE: It was reported that the owners have now taken on the role of staff recruitment for the home. At the time of inspection there was one full time vacancy. The vacant hours were being covered by part-time staff doing extra hours and also by the occasional use of relief or agency staff. Staff recruitment records were seen in relation to two staff. Records contained application forms, references, identification and training certificates. Induction checklists had been completed and there was evidence that both staff had received regular supervision. Criminal Records Bureau (CRB) checks had been obtained. The acting manager advised that the home are updating their records to ensure that a full CRB has been carried out on all people coming into the home on a paid basis such as hairdresser, maintenance and aroma22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 19 therapist. Interviews for staff have previously been held in the home but a decision has now been made that interviews will be held at the head office. One of the owners was in the home for part of the inspection and she advised that they have now changed their reference request form so that they ask for more in-depth information about prospective employees. Records show that all staff are up to date with mandatory training. Fire safety training had been arranged to be held the week following the inspection. In addition staff have opportunities to attend courses that are autism specific and it was reported that the staff team have all attended a variety of courses in the past year. One member of staff is currently studying for NVQ level three. Another staff member is currently working through their induction and it is anticipated that they will commence training on completion of their induction. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is well run. The systems in place to review and improve the quality of the care provided are good and are being developed further. The reinstatement of the monthly-unannounced visits by the proprietors should also assist in improving the quality of care. EVIDENCE: Since the last inspection the registered manager has transferred from the home to work in another home within the company. The senior carer is now working as acting manager. She advised that she would be submitting her application form to register as manager in the near future. She completed NVQ level four in June 2006. Minutes of staff meetings showed that various topics are discussed and that clear advice is then given to staff on the action to be taken. Instructions to 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 21 staff are explicit and can appear strict but the acting manager advised that the residents respond well to this, as they need strict boundaries. When this is not in place they feel confused and levels of challenging behaviour increase. One of the residents also raised this during a quality-monitoring visit with the proprietor, when she stated that she likes to know exactly what is expected of her. The manager advised that, with the introduction of clearer guidelines for staff and monitoring for consistency, incidences of challenging behaviour have significantly reduced in recent months and the residents appear much happier. As part of the home’s quality assurance system satisfaction questionnaires were sent to the relatives of the residents. Each of the relatives provided comments. Where issues were raised the manager telephoned the relative to discuss the issue and the outcome was documented on the reverse of the form. The acting manager advised that as a result of the questionnaires some changes were made including, menus were reviewed, the home are introducing new foods for one resident, residents are now making their own lunches and one of the residents is also making her own breakfast. Satisfaction questionnaires were not distributed to residents last year. The acting manager advised that this would be done this year and that comment received from relatives would be included in the home’s service user guide. As part of quality assurance the home are introducing a medication questionnaire to test staff periodically to ensure that they remain competent. They are also introducing a suggestions box for residents and visitors to the home to provide their views. There were lots of compliments cards and notes on file form relatives and visitors to the home detailing gratitude for the staff’s professionalism and support. As part of the inspection process attempts were made to contact the relatives/friend of two of the residents. This was achieved in relation to one resident only. Feedback received was very positive with comments such as ‘the care is very good’ and the resident ‘has moved on in leaps and bounds since moving into the home’. As part of the inspection process comment cards were sent to the home prior to the inspection for distribution to the residents. Two comment cards were received prior to the inspection. Both residents choose to tick responses rather than make comments with the exception of the question on ‘Do you know who to speak to if you are not happy’. For this question both residents detailed whom they would speak to if they were not happy. All other ticked responses were positive. The company arranges for one of the managers from one of the other homes within the group to visit on a monthly basis unannounced and to report to them on the conduct of the home. Records showed that visits were carried out in June and August 2006. However, the owners have advised that it is their intention to take on the responsibility for carrying out these visits and a visit 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 22 had been carried out earlier in February 2007. The report was detailed, identified areas where improvements were required and what action was required to address them. The acting manager advised that she found the visit very helpful, particularly as she is still relatively new to the manager’s role. One staff member has recently been designated health and safety rep for the home and she is due to attend training on the subject. There are a range of measures in place to ensure the health and safety of residents and staff. Records showed that carbon monoxide tests are carried out monthly, portable appliances are tested annually. Tests of hot water temperatures are meant to be carried out weekly in line with the home’s policy but records showed that generally they are done on a monthly basis. Hot water temperatures were tested at one outlet during the inspection and the reading was within safety limits. 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 X 2 4 2 X X 3 3 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 6(a) Requirement Timescale for action 30/04/07 2. YA20 3. YA24 4. YA32 The statement of purpose must be amended to reflect the changes in the management of the home. 13(2) Attention must be given to ensuring that there are no gaps in the recording of medication administered to residents. 23(4)(e) Fire doors must not be propped open. Where it is assessed that fire doors should be kept open then self-closing devices must be fitted. 18(1)(a)(c) Arrangements must be made for 50 of the staff team to receive NVQ training to level two or above. [This was a requirement of the previous inspection timescale 15/2/06] 9(1,2) 24(1a)(b) The acting manager must apply for registration as manager. As part of the homes quality assurance system they must seek the views of the residents on the quality of the care provided in the home. Comments received must be included in the home’s service DS0000045882.V297597.R01.S.doc 30/04/07 30/04/07 31/07/07 5. 6. YA37 YA39 30/04/07 31/05/07 22 St Peter`s Road Version 5.2 Page 25 user guide. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 22 St Peter`s Road DS0000045882.V297597.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!